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care map

Fall semester junior year

Karen Grile

on 20 March 2013

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Transcript of care map

allergies Carvedilol
Sulfa Drugs Background 69 year old
64 inches
103.62 lbs
full code
lives with husband at home
on disability
Caucasian, speaks English
no religious preference
learning style is verbal
enjoys watching TV and crossword puzzles at leisure activities past hospitalizations Ileac Bypass (2007)
Dialysis (2011-present)
"Implants placed in back to hold spine in place" family hx Cerebrovascular Accident
Coronary Artery Disease
Cancer Vaccinations Influenza (Oct. 2012)
Pneumococcal (2012) Chief Concern Dyspnea
Respiratory Distress Lab Values WBC 15.96 (high)
RBC 2.72 (low)
MCV 110,3 (high)
Hgb 8.9 (low)
Hct 30
neutrophils 14.99 (high)
lymphocytes 0.59 (low)

Na 134 (low)
K 5.0
Glucose 134 (high)
Cl 97 (Low)

BUN 61 (high)
Cr 3.66 (high) medication prednisone (predniSONE) 40mg Qday PO
ramipril (Altace) 5mg BID PO
diphenhydramine (Benadryl) 50mg Q4H PRN IVP
clotrimazole (Mycelex Troche) 10mg 5xD MM
gabapentin (Neurontin) 100mg Q8H PO
calcium acetate (Phoslo) 1334 mg Cmeal PO
nebivolol (Bystolic) 10 mg Daily PO
heparin sodium (Porcine) (Heparin) 5000u Q8H SC
levofloxacin (Levaquin) 500mg QDay PO
promethazine HCl (Phenergan) 25mg Q4H PRN PO
hydralazine HCl (Apresoline) 100 mg BID PO
insulin human lispro (HumaLOG) protocol INS4 SC
acetaminophen (Tylenol) 650 mg PO/PR
sodium chloride 3ml@3mls/min Q8H
amlodipine besylate (Norvasc) 10mg HS PO
buspirone HCl (Burspar) 10mg BID PO
formoterol fumarate (Foradil Aerolizer) I cap BID INH
acetaminophen/hydrocodone bitart (Lortab 10/500mg) 1 tab Q4H PO
levalbuterol HCl (Xopenex con 1.25 mg) Q4H WA INH
oxycodone HCl (Roxicodone) 5mg Q8H PRN PO inflammation
spot on sacrum
neuropathic pain
gastric reflex disease
prevent thrombi
nausea & vomiting
mild pain
IV flush
COPD & asthma
severe pain main medical dx respiratory failure
CHF lungs cant properly remove carbon dioxide tissues are not able to get enough oxygen heart cant pump blood to the rest of the body or get rid of extra fluid Assessment Pt came to ER four days ago with dyspnea and respiratory distress. Was diagnosed with respiratory failure, CHF, and hypoxia. review of systems: HEENT: Pt has a hx of cataracts with implants in both eyes. Has dentures on ton and bottom. Has a history of dysphagia. Speech pattern is slurred but still understandable. skin: Pt's skin is pale. Bruise on left arm from "infiltration of dialysis" wound of left lower back covered with bandage. skin is thin, especially in feet. Veins are visible in feet. No signs on cyanosis, edema 2+ in right leg. cardiovascular: Pt has hx of HTN, hypercholesterol, aortic valve malfunction, CHF, angia. cap refill of <3 seconds in finger. Right ankle has 2+ edema. Dorsal Pedal and Radial pulse 2+ Hematology: Pt has a hx of anemia, had a blood transfusion with colon resection Respiratory: Pt has hx of asthma, COPD, wheezing, emphysema. Is on 4 L/min nasal cannula continuously at hospital and at home. A&P ration of 1:2. Coarse throughout lungs, especially a the bottom and on expiration but states that is normal for her. Pt states a productive cough on occasion with clear thick mucus. Pt states she feels SOB with movement but not when resting. No accessory muscles used. Regular chest expansion without masses, crepitus, or tenderness. GI: Pt has hx of GERD and GI bleeding as well as gallbladder disease and crohn's disease. Pt has a distended, soft, abdomen with hyperactive bowel sounds in all quarters. Pt has had diarrhea this morning with some flatus. Renal: Pt has Dialysis for 3hours on Monday, Wednesday, and Friday with a fistula bilateral Left. Urinary output of 150ml this morning yellow and clear. Dialysis port in left chest. Endocrine: Pt has history of diabetes controlled with insulin. Musculoskeletal: Pt has chronic back pain- uses a pain stimulator in left buttock, had hardware placed in lumbar spine. Has a hx of falls and is a fall risk 3. she is able to sit up on her own and her husband helps her when she needs to get up. Does not use a walker or a wheelchair. Neuro: Pt is alert to name and oriented to place and time. Speech is slurred but easily understood. Psychiatric: Pt states a history of anxiety. Reproductive: Pt states she is sexually active with husband and uses no form of contraception. Social: Pt report smoking 4 cigarettes daily, 29 years ago, she smoke 2 packs per day. Pt says she does not use drugs or alcohol. She states she drinks very little caffeine, about 1 cup of coffee a day. Pt is on a regular diet. Vital Signs:
Temp 97.5 oral
BP 126/40 right arm
Pulse 64 bpm
Resp Rate 20
O2 stat 95% on 4L/min nasal cannula
chronic pain level of 5 at back and feet Diagnosis #1

Impaired gas exchange r/t SOB aeb SOB with ambulation. short term goal pt came to ER with dyspnea and was diagnosed with respiratory failure and hypoxia. Pt reports being SOB when moving. Because gas exchange keeps the organs living, this is the most important diagnosis Pt will remain free of signs of respiratory distress such as SOB and anxiety while on shift. Assess respiratory rate, depth, and ease of respiration Q2H. Watching for accessory muscle and nasal flaring By assessing respiratory rate, depth, and ease of respiration, noting accessory muscles used and nasal flaring, I can watch for early
signs of respiratory distress. Auscultate breath & lung sounds Q2H changes in breath sounds and patterns could be a sign of respiratory distress assess pts behavior and mental status for the onset of restlessness, agitation, confusion, and lethargy Q2H these are signs of respiratory distress and anxiety Assess O2 stat Q4H reporting readings of less than 90% An O2 stat tells how much oxygen is delivered to the tissues. Because the pt has hypoxia, an O2 stat will state how much oxygen is getting to the tissue. An O2 stat less than 90% is considered to be the lowest number for normal and could be a sign of potential respiratory distress. continue to administer O2 through nasal cannula at 4L/min the pt is on O2 at home and at the hospital. this will help her to constantly receive the amount of air she needs assess for anxiety, agitation, and insomnia Q4H these are signs of respiratory distress and anxiety If pt is experiencing SOB, have pt lean over bedside table, resting elbows on table this position helps people who are having trouble breathing breath better long term goal Pt will understand how to ambulate without becoming SOB aeb stating 3 different ways before discharge. teach client to eating small meals frequently and use dietary supplements this will help client get the nutrition she needs without becoming SOB while eating teach client to use a wheeled walker or other ambulation devices the use of a wheeled walker has been shown to result in significant decrease in hypoxemia and SOB during a 6-minute walk test instruct the client to keep the home temperature above 68 degrees and avoid cold weather cold air temperature causes constriction of blood vessels, which impairs the client's ability to absorb oxygen. this is especially important when the patient will be ambulating teach the client how to perform pursed-lip breathing and inspiration muscle training, and how to use the tripod position when feeling SOB pursed-lip breathing decreases breathlessness and improves respiratory function refer client to home health aide services as necessary for assistance with activities for daily living due to client becoming SOB with ambulation, activities of daily living can become difficult teach client the importance of taking breaks when being active and performing activities of daily living pts who suffer from respiratory distress and SOB can easily become SOB during dailies of activity living. Breaks are necessary in order for pt to perform activities Diagnosis #2

Fluid Volume Excess r/t ineffective contracting of the heart muscle aeb edema in right lower extremity short term goal pt came to ER with dyspnea and edema and was diagnosed with CHF. CHF causes excessive fluid. Pt will have decreased edema to 1+ in lower extremities by discharge Teach client to use diuretics as prescribed. Diuretics help to get rid of extra fluid by increasing urine output teach pt about the need for fluid restriction there is already excess fluid in the body and adding more fluid can make the problem worse teach the client why there is excess fluid in the body pt needs to understand the disease and the disease process because it is something she will be dealing the the rest of her life teach the client about signs and symptoms of excess and deficient fluid volume such as dyspnea,changes in volume and frequency of urine, weight changes, and edema and when to call the physician fluid volume can change rapidly with aggressive treatment teach the client to weigh self daily in the morning and notify physician if there is 3lb or more change by monitory weight daily, fluid retention can be caught early, reported, and fixed with medications. this can lead to the pt avoiding stays in the hospital. Teach client to watch for certain foods that cause them to to urinate more or less and avoid those foods certain foods, such as foods with high sodium will cause the client to urinate more, other foods can cause them to urinate less. this will affect the fluid volume of the body. long term goal Client will explain 3 actions that are used to prevent excess fluid volume by the end of shift teach the client about restricting sodium in diet by only eating 1500m a day, not adding salt to foods, using Mrs. K instead of table salt, and avoid eating packaged foods Sodium causes the body to hold onto extra water assess location and extent of edema, using the 1+ to 4+ scale Q4Hr Implement fluid restriction as ordered If there is too much fluid, edema can worsen Assess serum albumin level Q12Hr and provide protein as appropriate when serum albumin is low, peripheral edema may increase Assess VS, noting changes in BP and heart rate Q4Hr Edema and fluid retention causes a decrease in BP and cardiac output Provide a restricted-sodium diet as ordered Sodium causes the body to retain water, which causes edema hypotension, electrolyte imbalance, diarrhea, ace inhibitor adrenal hormone substitution hypotension, electrolyte imbalance, diarrhea, palpitations ethanolanine antihistamine topical antifungal burning, stinging, dryness, itching misc. anticonvulsion UTI, anxiety, leukopenia, rhinitis, cough, vasodilation fluid/electrolyte replacement constipation, anorexia, diarrhea, hypercalcemia beta adrenergic blocker insomnia, edema, bronchospasm, bradycardia, MI anticoagulant bleeding, hematuria, hemorrhage, anemia quinolone antibiotic phenazothiazine anti-emetics direct vasodilators leukopenia, headache, anorexia, muscle cramps, palpitations insulin misc. analgesic antipyretic fluid/electrolyte replacement dihydropyridne calcium CB palpitations, edema, insomnia, polyuria, hair loss, bradycardia non-benzo anxiolytics/sedatives beta adrenergic agonists anxiety, bronchospasm, tachycardia, HTN, insomnia opiate agonist analgesics beta adrenergic agonist anxiety, dysrhythmias, restlessness, hypokalemia, hyperglycemia opiate agonist analgesics hepatotoxicity, hemolytic anemia, insomnia, multiple organ failure drowsiness, constipation, bradycardia, rep. depression dry mouth, hypoglycemia, peripheral edema GI bleeding, hepatotoxicity, renal failure, drowsiness hypernatremia, fluid overload dry mouth, weakness, dizziness, hypoglycemia vomiting, confusion, hallucinations, urinary retention dizziness, hypotension, dysuria, wheezing HTN, constipation, retention, apnea nursing diagnosis Intervention reasoning abnormal lab values Evaluation Pt remained free of respiratory distress and SOB throughout shift. Pt felt comfortable breathing and no anxiety.

The next goal would be for the pt to be able to walk 3 labs around the floor, taken rests when needed Evaluation Pt was discharged during shift. She was able to state 3 different ways to not be SOB when ambulating. Client said she would take breaks while getting ready in the morning, would eat small meals, and if she felt SOB she would use pursed lip breathing

The next goal would be to teach the pts family when it is important to bring the pt to the hospital due to dyspnea Evaluation Short term goal Long term goal Key: assessing the location and size of the edema can tell us how much fluid retention there is administer prescribed diuretics as appropriate assessing BP before and assessing urine output after diuretics help to decrease fluid in the body, which decreases edema consult with physician if edema continues to increase to 3+ excess fluid can cause pulmonary edema Evaluation Pt. was able to state 3 ways to prevent excess fluid volume. She stated me the importance to restricting fluid, sodium, and weighing self daily. Goal will change to consult with the pt and pts family as to how they will implement ways to reduce edema when the pt returns home Evaluation Pt. was discharged during shift. She still had edema of 2+ at discharge. Goal should change to teach pt how to continue to decrease edema when she goes home as soon as discharge papers are written Karen Grile NURS 3350 care map Ackley & Ladwig 2011 p. 402 Ackley & Ladwig 2011 p. 404 Ackley & Ladwig 2011 p. 403 Ackley & Ladwig 2011 p.. 403 Ackley & Ladwig 2011 p. 402 Ackley & Ladwig 2011 p. 402 Raise the pts HOB to at least 40 degrees eases the pts ability to breathe Ackley & Ladwig 2011 p. 403 Ackley & Ladwig 2011 p. 404 Ackley & Ladwig 2011 p. 405 Ackley & Ladwig 2011 p. 405 Ackley & Ladwig 2011 p. 404 Ackley & Ladwig 2011 p. 404 Ackley & Ladwig 2011 p. 394 Ackley & Ladwig 2011 p. 395 Ackley & Ladwig 2011 p. 395 Ackley & Ladwig 2011 p. 396 Ackley & Ladwig 2011 p. 396 Ackley & Ladwig 2011 p. 394 Ackley & Ladwig 2011 p. 395 Ackley & Ladwig 2011 p. 394 Ackley & Ladwig 2011 p. 395 Ackley & Ladwig 2011 p. 395 Ackley & Ladwig 2011 p. 396 References Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based bide to planning care. Maryland Heights, MO: Mosby.
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